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One Day in the Life of a Meaningful User

All the laws have been passed and all the final rulings have been published. In the spirit of the times, you went out and got yourself an EHR. You did your due diligence and sat through many hours of vendor demonstrations. In the end they all started to blend together, so you talked to friends and colleagues and accepted the Hospital’s offer to pay a big chunk of your EHR costs if you picked the one they wanted you to pick.

Your biller quit in disgust, but other than that the implementation was uneventful and the Hospital folks helped a lot. After several hiccups, your Medicare payments are coming in regularly now and your office is adjusting well to the new software. The documentation templates leave a lot to be desired, but you type well and when you find some free time you may take a stab at customizing them a bit. Here and there you run into bugs and a couple of times the EHR was unavailable for a good two to three hours. Not sure exactly why. Maybe it was the Internet that was unavailable.

Anyway, if all goes according to plan, you will be retiring in 10 years and your much younger partner will be bringing in someone who is probably in Medical School right now. Everything seems under control. But today is different…

Today is January 2nd, 2011 and you are driving to work. Today has to be meaningfully different and your first patient is waiting in Exam Room 1.

Mrs. Kline is a pleasant 68 year old woman, who has been seeing you for ten years or so, for her hypertension (which is well managed), hyperlipidemia and a touch of arthritis. You bring up her chart on your EHR and begin your meaningful use (§ 495.6(d)(7)(i) – Record Demographics – Check). There is a little red sign on the screen saying that Mrs. Kline is overdue for a routine mammogram (§ 495.6(d)(11)(i) – Clinical Decision Support – Check). She says that she got a little postcard from your office the other day (§ 495.6(e)(4)(i) – Patient Reminders – Check) and will be making an appointment soon. You look at the BP recorded by the nurse and also notice that Mrs. Kline gained some weight and her BMI is now well over 30 (§ 495.6(d)(8)(i) – Record Vitals and BMI – Check). You chuckle as you notice that the nurse duly noted that Mrs. Kline does not smoke (§ 495.6(d)(9)(i) – Record Smoking Status – Check). As you listen to Mrs. Kline’s account of her knees “acting up” again and how it is now painful to walk Fluffy in the morning, you glance at her problem list (§ 495.6(d)(3)(i) – Maintain Problem List – Check) and medications (§ 495.6(d)(5)(i) – Maintain Med List – Check). She also mentioned some shortness of breath when walking Fluffy and you proceed to do an examination.

As you look over Mrs. Kline’s slightly swollen knees and check her wrists and elbows too, she tells you about her daughter Ellie and how she is now a third year Dermatology resident. Mrs. Kline is hesitantly wondering if her daughter could peek at her medical records once in a while. Sounds reasonable and you tell her to ask Mary at the front desk to set her up with access to the portal (§ 495.6(d)(12)(i) – Electronic Copy of Medical Records – Check). You explain to her that all her records are on the computer now and even today’s visit summary will be there before she gets home (§ 495.6(d)(13)(i) – Provide Visit Summaries – Check) and (§ 495.6(e)(5)(i) – Timely Access to Medical Records – Check). Her daughter in faraway California should be well informed from now on.

The exam was non eventful and the Lipid panel Mrs. Kline had last week looks good (§ 495.6(e)(2)(i) – Incorporate Lab Results – Check). You proceed to write a new prescription for Celebrex (§ 495.6(d)(1)(i) – CPOE for Meds – Check) and note that she is not allergic to anything (§ 495.6(d)(6)(i) – Maintain Allergy List – Check). The obligatory DDI pops up and you dismiss it as duly noted (§ 495.6(d)(2)(i) – Drug-Drug Interaction – Check). You adjust the BP meds and note that everything is on formulary (§ 495.6(e)(1)(i) – Formulary Check – Check). You ask Mrs. Klein which pharmacy she is using and promptly send all her scripts there (§ 495.6(d)(4)(i) – Electronic Prescribing – Check). On your way out you talk to Mrs. Kline about the need to monitor her blood pressure carefully now that she is on new meds and to call you if anything changes before her next appointment. You say good bye and good luck to her daughter. Mrs. Kline stops by the front desk and Mary sets her up with a portal account, makes an appointment for her and hands her the BP home monitoring education materials you ordered (§ 495.6(e)(6)(i) – Patient Education Materials – Check). Your next patient is in Exam Room 2.

As you walk over to your office, Mary mentions that the IT guy will be coming in later today to fill out some security survey (§ 495.6(d)(15)(i) – Protect Electronic Health Records – Check) and test the export function one more time (§ 495.6(d)(14)(i) – Capability to Exchange Clinical Data – Check) and he is certain that it will work this time. There is a new patient in the freshly cleaned Exam Room 1.

It’s after five o’clock and light snow is falling outside. You saw 20 patients today; some with chronic conditions, some very ill (one had to be admitted) and others with incidental scrapes and viruses, but pretty healthy otherwise. There was nothing unusual about today. On your way home you briefly consider that at this rate you should have plenty of data to report to CMS in 3 months (§ 495.6(d)(10)(i) – Report Quality Measures to CMS – Check) and Mary with the IT guy should figure out the rest when the time comes. That Christmas bonus was well deserved.

This was just one of the 3,653 days until your retirement. The extra three are for leap years.

Congratulations, you are now a Meaningful User of EHR technology.

Margalit Gur-Arie blogs frequently at her website, On Healthcare Technology. She was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization.

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58 replies »

  1. Propensity,
    I just realized that you also posted here about your desire for a search engine feature within an EHR. Please see my comment in the “What’s in an EHR” posting if you want to see a working demo of such a feature: https://thehealthcareblog.com/the_health_care_blog/2010/08/whats-in-an-ehr.html My biggest frustration has always been that we not only need to search for answers about patient-specific questions (“Did this patient ever get the shingles vaccine?”), but we also need to search for clinical questions (“Can and should I give this patient who had shingles ten years ago a vaccine?” AND administrative questions (“Does this patient’s insurance cover the shingles vaccine?”). All of those questions end up wasting my time trying to find an answer. I don’t want to make this posting into a sales pitch, but that is exactly what my company does http://www.medsocket.com After we get our pilot up and running at the University of Missouri, I hope to share some more data on how much of an impact this type of search feature can have on satisfaction, improved patient care, time savings, etc… So, you don’t have to sell me on the idea of why we need better search tools for providers. Cheers. -Karl

  2. I have no desire to spread the wealth, I want as much of it right, points down to name, here as I can hold. The only time I want to spread the wealth is when my cup run overith I like a nice spread out spill instead of big puddles

  3. “Doctors need to stop their whining and open their wallats like the rest of us do. They already live better then 95% of us, I’m getting tired of passing the hat to pay their expenses while they live in bigger houses, drive nicer cars, and have younger wives. ”
    That is not a very capitalist way of looking at things. Careful Nate, this sounds almost like a desire to “spread the wealth” around…. 🙂
    As to paper records, Rich’s story is very typical and there are very few questions in my mind regarding the need for digitizing clinical information. The cost should be born by the immediate beneficiaries, whoever they may be, not by those who happen to have enough money to pay out.

  4. wonder how much time is spent taking redudenent medical histories? From my personal experience both in regards to medical and non medical digitliastion of data utilization of the data is far less labor entensive. Getting analog data to digital is tough, and the first few weeks of transtion from analog to digital takes som egetting use to but after that there is no question it saves time and is more efficient. I don’t see how using digital data can be more labor intensive then charts that get filed and passed around.

  5. “Yes, but, again, information is not health care. To use all this newly accumulated information in a “meaningful” way will not be like sending out a bank statement; it will require the doc and her staff to use that information in a way that has a positive impact on an individual’s health. And that is very labor-intensive and expensive.”
    In my experience this week at a leading childrens hospital, my wife and I were queried for relevant medical history information about our child, by various medical professionals in the context of a pre-op meeting – anesthesiologists, nurses, nurse practitioners, doctors. I assume they are engaging in this search for information to provide the best care. Neither my wife or I are medical professionals, we also don’t have perfect recall. I know our answers were incomplete. At one point we differed on our response to a question about how old our child was when a certain procedure was done – I wonder how the medical staff process this – do they take my wife’s estimate, or mine? on what basis, e.g. who sounded more confident? throw them both out? average them? For the record I trust my wife’s memory better than mine. One nurse had a big book of hardcopy records ( no automated search of course although she did spend a lot of time flipping through pages ). We did identify for her an error in her hardcopy which she acknowledged and promised to “send upstairs” to get it fixed. Seems to me its already labor intensive and expensive.

  6. “I don’t know who benefits more.”
    “Nate, regarding EDI, it is only fair that insurers pay most of the price since they realize most of the efficiencies of electronic claims.”
    Before you were certain that it benefited insurers and thus they should pay for it, I think you intended and do build upon this to justify insurers, taxpayors, and others getting stuck with the tab for EHRs.
    While still wrong I can respect and leave it at you don’t know. Maybe you just don’t beleive the math I showed you but it is pretty basic and indisputable. None the less I hope your initial inaccurate beleif doesn’t perpatrate into your EHRs arguemnt.
    Doctors need to stop their whining and open their wallats like the rest of us do. They already live better then 95% of us, I’m getting tired of passing the hat to pay their expenses while they live in bigger houses, drive nicer cars, and have younger wives.

  7. What does EDI have to do with being liberal, or not?
    I have no idea what you are trying to say. Is it that payers are better off on paper? Or are you just saying that providers benefit more than payers from EDI? Does this mean that the Government required EDI to help doctors out?
    I don’t know who benefits more. I think both do, or should. If that’s not true, maybe we should ask UHC if they are interested in reverting to paper.

  8. “Nate, when is the last time you actually looked at an 837?”
    two hours ago, I imported 450 of them today, how about you?
    Nothing in your latest comment changes the fact that collecting does not impact EDI fees or savings. You have not presented a single credible argument that insurers benefit from EDI more then providers. You made an unsubstantiated claim, got called out on it, and refuse to admit you were wrong. EDI saved doctors paper and postage while insurers had data entry cost off set by EDI fees. You don’t have any argument here, just fix the mistake and move on to more important things. Why do you liberals fight to the death over trivial errors. Its like your afraid if people see you were wrong on this they might think you where wrong on everything else. Denying the obvious is far worse then admitting you had some incorrect beliefs.

  9. Nate, when is the last time you actually looked at an 837? It has dozens of loops and a very complex structure. There are required elements and optional ones. Each element has a predefined format and each payer has its own special rules. Ever so often, billing software will send 837s which are missing required elements, have incorrectly formatted data (e.g. something that should be characters only has numbers in it) and a myriad other things. Clearinghouses stop those 837 and send a message back to the provider that they need to be fixed. Sometimes entire batches fail at the clearinghouse. You never see those. Go check with your clearinghouse.
    As to collections, yes, patients are hard to collect from, but most of the money comes from insurers and collecting from them is no walk in the park either. I suggest you go visit a billing company and see for yourself how much time is wasted trying to collect from payers (working denials, spending hours on the phone, refiling, crossing to secondaries, appeals, etc.).

  10. “Providers who outsource billing pay between 5% and 10% of net collections for the service,”
    Come on Margalit your mixing terms in the same sentenance. Are they billing or collecting? It is much more expensive to collect money then it is to send out a bill. Your 5% or 10% has nothing to do with the cost of billing that is almost all collection. Net collections….hum nothing in their seems to preclude patients, or are you claiming patients are easier to collect from then insurers? Same with billers you should no better then to think paper billing doesn’t require a biller to do the coding.
    “clearinghouses do perform a valuable service by rejecting incorrectly formatted claims.”
    This leads me to believe you have no idea at all what EDI is. I’m not even sure what an incorrectly formatted claim is. 837 is 837, by federal law I have to accept it, there is no allowance for me to reject an 837 cause I don’t like the font they used. If they send an 837 we have to take it so this benefit you think is out there doesn’t exist.
    “There used to be small clearinghouses that charged insurers flat fees instead of per-click,”
    There use to be hamburger joints that sold burgers for $0.10 but I guess the public wasn’t interested in supporting them. Or maybe they went out of business becuase it cost more to process 1,000,000 claims then it does 100?
    HIPAA EDI regs where a government handout to providers forceavbly extracted from payors. The funny thing is payors wouldn’t have minded nearly as much footing the bill if providers had just been required to use it.

  11. Wendell, one obstacle I see is that EHR data is not uniformly structured. There are labs, for example, in codified format and the same labs in scanned documents, of such low quality that not much can be extracted, and some things are in textual format. It also depends in which context a particular term appears.
    Not sure of the magnitude of the job here, but it could be an exciting adventure for someone brave enough 🙂

  12. Yes, a fire or a flood would destroy all paper medical records. I ran into a practice a few years a go that got robbed and they took everything that wasn’t nailed to the walls, including all the charts. I think after Katrina the VA EMR proved its value pretty decisively.
    However, if you are ever going to help docs make the transition, you must listen and understand their concerns. Many are legitimate.
    2K per month for a solo doc is a lot of money. Putting data in the cloud, when you have no idea if you’ll ever get it back, or who else is looking at it, is disconcerting. The prospect of losing Internet connectivity and getting stuck with an office full of patients and no charts is downright alarming.
    The quality of EMR produced documentation bearing more resemblance to an automated phone system message, that lasts forever, than to any human created content could become an impediment to providing care.
    I still believe that the benefits are greater than the shortcomings, but every story has two sides and the EHR story seems to have at least seventeen different facets.

  13. Nate,
    What providers pay for the clearinghouse is only part of the story. They also have to pay for software license, hardware and the biller who now has different work, but it is still payroll and probably higher than an envelope stuffing person. Providers who outsource billing pay between 5% and 10% of net collections for the service, which should give you an idea of how expensive it is to bill insurers.
    As far as insurers go, clearinghouses do perform a valuable service by rejecting incorrectly formatted claims. I don’t believe insurers have to pay for those. This service should be worth something.
    There used to be small clearinghouses that charged insurers flat fees instead of per-click, but I guess the industry was not interested in supporting them (ProxyMed was one) and stuck with the more expensive big boys. Go figure…

  14. “‘Google’ searching a Chart or an entire rack of Charts is just one of the benefits to come”
    All Google’s software does whether on a computer or across the Internet is to create indexes (indices) to data, the exact equivalent is an index to a book.
    Lucene is FOSS written originally in Java, then “ported” to other languages, that provides an API for indexing any application and its data. There is certainly similar indexing software provided by Microsoft for its products.
    I am still surprised if such search features are not incorporated in all major EMR applications.

  15. “And as pcp often argues, the remainder of the “savings” are easily offset by the necessity to hire IT people and purchase servers.”
    This is 2010, they should be on a managed cloud anyways. All the server and IT help they would need would be less then 2K per month. How are they backing up their files now, if a doctor’s office burns down are all those medical records gone for ever? If a crackhead breaks a window they really have access to 1000s of people’s PHI? How much do they pay per Sq’ to lease office space to store paper? Could probably almost pay for the computers and IT just with that savings.

  16. “Nate, regarding EDI, it is only fair that insurers pay most of the price since they realize most of the efficiencies of electronic claims.”
    um, really? Have you actually done the math or just “know” this? In the past a doctor would pay for;
    1. Cost to print the bill
    2. Cost to stuff in envelope
    3. Cost of paper and envelope
    3. Postage to have it delivered
    I see $0.60 to $0.70 easily there
    Payor would pay cost to open and data enter, This runs around $0.50. With OCR it was substantially less. Once the data entry is done there really is no difference.
    Most doctors pay nothing for EDI or a flat nomial amount like $100 a month, so they basically save $.69 per claim.
    The insurer has to pay to receive the claim, depending on their size $0.40 to $0.50 roughly. They save at most $0.10 or break even. But it doesn’t stop there, they pay EDI fees for every claim, if a doctor duplicate bills you pay duplicate fees. If the doctor sends you claims for a group that termed 5 years ago you pay the fee, claims that never would have been data entered with paper.
    My analysis comes from actually paying the bills. Will you share your numbers Margalit and how you calcualte that insurers are the ones saving money.

  17. Thanks, David. This is exactly what I was trying to do for all those doctors out there who are apprehensive about biosurveillance, nominator/denominator, LOINC, SNOMED, CCD/CDA, HITSP, NHIN and all the new and unfamiliar terminology flooding us every single day.
    Meaningful Use is what physicians do everyday.
    And yes, EHR will also allow them to do more in due course, Google searching a Chart or an entire rack of Charts is just one of the benefits to come.
    What I find interesting is that the Google search request came from a physician user (I presume propensity is), which is just an example of how getting more users on these systems can advance the industry by leaps and bounds.

  18. Well written, Margalit. I don’t think you intended this as a controversy-generating piece, and obviously it’s just hypothetical (“your mileage may vary”). Whether or not someone agrees with the specifics or even with the premise of EHRs as beneficial, I think it’s useful to visualize “use” rather than speak abstractly in techno-speak, standards-speak, or legalese, so your putting in plain English is helpful.
    One thing that might help flesh out the story is to discuss the other things that an office physician would do that are outside of the “MU” umbrella. I’m pretty sure you didn’t intend to imply that the “MU” functions are all that matters, but since the narrative was wrapped around MU criteria, it might have been interpreted that way.
    BTW, I thought that the “Google search” suggestion was a great one. Ironically fulfilling such a request isn’t possible on paper: it requires that the information has been made electronic in some form, i.e., an longitudinal “electronic health record” (though ehr in lower case, not necessarily only a Certified EHR). Right now, the Googling is done in the limited brains of the physician and the patient, and the search results differ every time!
    Thanks,
    David

  19. Thanks, Dr. Walker. For propensity’s sake I hope someone is….
    Nate, regarding EDI, it is only fair that insurers pay most of the price since they realize most of the efficiencies of electronic claims.
    Malpractice fees may go down, but by the same token, they may go up, since the attorneys will now have access to a wealth of data they could only dream of before EMRs.
    Illegible scripts can be avoided by either faxing or printing from an EHR. It is not necessary to use electronic transmission, but it does save the pharmacy some typing, so maybe they should bear some of the costs as well.
    And as pcp often argues, the remainder of the “savings” are easily offset by the necessity to hire IT people and purchase servers.
    It is not as clear cut as we would like it to be, and since tax payers are already contributing several billions to the effort, I believe insurers should contribute their part as well.

  20. Margalit;
    Great post, and great rejoinders to our cadre of demoralized physicians who inhabit this blog. I remain convinced that this skepticism is a generational phenomenon and will disappear as the new IT-savvy generation of docs takes hold. Not that I am without sympathy for the transitional generation; it is they who must bear the burden of working out the bugs, and bugs there will be. But my experiences as a patient and family member have irrevocably convinced me that this is the direction we must take.
    Parenthetically, I did write to the FDA regarding the necessity for approval of CPOE and other components of the EMR, and did actually receive a reply, after awhile. One may take it at face value, but at least it provides a name and address for those who wish to also write:
    “Dear Dr. {bev},
    Thank you for your email of June 25, 2010, in which you raise questions about the Food and Drug Administration (FDA)’s regulation of the Electronic Medical Record (EMR).
    In particular, you ask about the intention of FDA or other governmental agencies to regulate EMRs and whether current government thinking about the regulation of EMRs is publicly available. The FDA in conjunction with the Health and Human Services, Office of the National Coordinator for Health Information Technology and other government agencies are evaluating what, if any, steps the federal government should take to assure patient safety when using health information technology products. When we have reached a conclusion based on our evaluation, we will make our thoughts available for public input.
    Again, thank you for taking the time to write on this very important issue.
    Nancy Stade
    Acting Associate Director for Regulations and Policy
    Center for Devices and Radiological Health

  21. Great post again, Margalit. If the medical data becomes parsed / structured, then it will essentially be a database – and a search feature will soon emerge (someone who read your blog is probably already developing one for an EMR at this very minute).

  22. ” If cost savings largely accrue to taxpayers, insurers and patients, it suggests that taxpayers and insurers should probably pay for all or at least most of the upfront cost of implementation.”
    Providers got a 100% free ride on EDI while pocketing 95% of the savings. What savings do insurers get? A test that shouldn’t have been ordered in the first place might not be now? Isn’t that rewarding providers for years of poor performance?
    Won’t providers get an qual if not larger benefit;
    1. Reduce Malpratice claims
    2. Reduce prescribing errors and calls from pharmacies asking what the heck the scribbles are suppose to mean
    3. Reduction of storage cost
    4. Reduce cost of copying and sharing records and staff time
    5. improved efficency
    Doctors will benefit from EMRs well before any one else, just like they reaped most of the savings from EDI and paid nothing for it.

  23. I remain anxiously waiting for someone to point out which EMR and CPOE devices have search functions for tests, medications, and diagnoses of past years.

  24. I see that today the feds passed legislation regarding the states and how medicaid should adopt meaningful use to obtain the federal stimulus funding….So the states have to implement and track meaningful use to obtain their stimulus funding, and the feds are going to have to track the docs who use or do not use emr with meaningful use. Sounds like a lot of new overhead…Whatever is saved will be be far outweighed by the increase in medicare and medicaid bureaucracy. Medicaid incentives are a joke…..Insanity reigns!!!!

  25. Several years ago, the UK’s National Health Service implemented a pay for performance scheme for its primary care physicians. Doctors were evaluated on no fewer than 146 separate metrics with points assigned to each adding up to a maximum possible score of 1,050 points. Most of the docs did better than expected under this approach and earned substantial bonuses which drove incomes for most of them well above where it had been previously. As I understand it, that remains the case today. The upshot is that the data gathering and analytics needed to evaluate each doctor’s performance would not have been possible without the use of electronic records. At the same time, the aggregate data can be used to spread best practices and better understand what works and what doesn’t.
    That all said, the issue of who should pay for at least the initial purchase of hardware, software and training is a legitimate one. If cost savings largely accrue to taxpayers, insurers and patients, it suggests that taxpayers and insurers should probably pay for all or at least most of the upfront cost of implementation.

  26. Good for Margalit for these postings. Probably the best writer here and her native language is not even English!
    “generally, it seems to be some vague wish to “fix” the entire health care system”
    There is nothing whatsoever vague about the benefits from universal implementation and use of EHR/EMR/PHR systems. Various estimates on cost savings are indicative rather than even remotely precise, but the orders of magnitude and positive direction are accurate.
    I repeatedly assert that on-line presence of medical service providers, universal availability of more or less complete medical data more or less immediately could offer the conditions for more competitive determination of medical service supply and its pricing. That would benefit society as a whole enormously and do little if any harm to the interests of the service providers, despite the fears about that among some providers.
    The enhanced quality of service is two-fold: (1) more or less automatic transfer of relevant data from one medical service provider to another – something that enhances accuracy, reduces the vast duplication of effort and reduces hassle to a patient (2) availability of clinical data instantaneously to any given service provider. Less guesswork for decision-making and diagnosis.

  27. Dr. E., you are either not completely reading what I write, or are blinded by your political opinions. I see and fully acknowledge the multiple problems with HIT, but the sum total I come up with is positive nevertheless. Your evaluation may be different and you may of course disagree, which is fine. However, I fail to see how the current resident of the White House, or his mother, have anything to do with this.
    “When money is to be made for applying an intervention, those paying or participating need to know if there is a profit motive.”
    You may want to rethink this sentence since it disqualifies both of us, and every living human being, from discussing health care.

  28. ANECDOTES? “pcp, let’s look at a purely anecdotal example I just witnessed a couple of weeks ago.”
    There many reports on the FDA MAUDE database depicting death, injury, risk, CPOE breakdown, CPOE defects, misidentification, inappropriate radiation, dnager causing lack of usability, etc. The FDA states this is the tip of the iceberg.
    DAVID BLUMENTHAL blows them off, depreciates them, ignores them, etc as anecdotes.
    Hey guys, send more of these anecdotes of death to the FDA.

  29. I disagree with how you claim you are coming across in your postings and commentary thread comments; you are basically selling this technology as a viable and effective medium with little consequences, and are quick to debate any disagreement, per the repeated comments at this thread alone. Sorry I am a skeptic and cynic, but, years of seeing others, as much as myself, get equally burned by technological “advancements” as much as benefitted is what I know, and I expect responsible dialogue to be occurring at these postings. And, have disclaimers at the end of posts like yours so unbiased and objective readers can get the “gist” of the agenda.
    Isn’t transparency what gets the most respect and response? Well, not if you embrace our current occupant in the White House. His mother forgot to instill the adage “deeds not words are what define you”, not just use the word “hope” in every other sentence, and not explain he really meant ” I hope you are not paying attention to what I do!”
    For someone using EHR at my current temp assignment, I see some strengths, but also concerning weaknesses, which I will not detail here by the way, so I think readers need to hear this from someone in the trenches who is wearing transparent lenses that do not color or occlude the experience!
    When money is to be made for applying an intervention, those paying or participating need to know if there is a profit motive. It may be benign in the end, but why should responsible and decent people expect that is the only agenda? What is the adage?: burned once, shame on me, burned twice, shame on you!?

  30. pcp, let’s look at a purely anecdotal example I just witnessed a couple of weeks ago.
    A pediatrician, still on paper, refers a patient to a cardiologist. The referral consists of a piece of paper with a phone number and verbal instructions to call and make an appointment. Nothing was sent from the peds office to the cardiology office.
    During the cardiology visit, an entire history was taken and the doc was about to order a 2D echo when the mom noted that an echo was done a few months ago in the same hospital where the cardiology office was located. The cardiologist was able to log into the hospital system and look at the echo which was normal and a redundant test was avoided, but this was just a lucky and atypical occurrence. In most cases the second echo would have been ordered.
    If all three entities were electronically connected, the cardiologist would have seen the histories, including the echo, right off the bat.
    In an electronically connected scenario, the pediatrician would save nothing and lose nothing. The cardiologist would lose another visit to evaluate the echo. The hospital would lose the reimbursement for another echo. The patient would prevent loss of time away from school (and work for mom) for both the additional echo and the cardiology visit. The insurer (or the high deductible patient) would save the price of an echo and a cardiology visit.
    Multiply this by millions and you have costs savings for the system and, perversely, financial loss for providers.

  31. Dr. Levin,
    I agree with most of what you wrote. If you notice, our doctor got his EHR from the hospital (which is a debatable decision), exactly because he probably has no money or credit.
    CMS is stating that they will start paying in the second quarter of 2011, if you are able to meet the Medicare collections threshold during the first quarter. Otherwise, they will wait until you do. I am more optimistic about Medicare incentives getting paid than I am about Medicaid, which is highly dependent on the States.
    In any case, I don’t think the incentives will cover the expenditures if you go and buy a fancy EHR on your own dollar. I do agree with you that those most likely to benefit financially from this arrangement should bear most of the cost burden (see comment above). Unfortunately, this is not currently the case.

  32. “computers do an excellent job at collecting, storing, analyzing and disseminating Information and therefore are capable of providing great efficiencies for information heavy endeavors”
    Yes, but, again, information is not health care. To use all this newly accumulated information in a “meaningful” way will not be like sending out a bank statement; it will require the doc and her staff to use that information in a way that has a positive impact on an individual’s health. And that is very labor-intensive and expensive. Computers have paid off in other industries because of reductions in work force; it seems like the uses of IT that you cited earlier would have the exact opposite effect in health care.

  33. Dr. E., I am not a physician, but that is not preventing me from understanding and appreciating what you do, just like you don’t have to be a soldier (even though I was) to appreciate what young men and women do for their country.
    I am not the enemy and I am certainly not an “avowed advocate” of anything in particular other than fighting poverty and lack of education.
    I am not wearing any Rose colored glasses when it comes to HIT. I am aware of the limitations, the bugs, the errors, the privacy issues and the lack of a solid business case.
    However, I will not wear Dark colored glasses either.
    pcp, yes, it does get tiresome. Propaganda always does. There is no solid evidence indicating exactly how HIT will provide returns for our investment, but there are indications from other fields on how it may reduce costs. Perhaps it is wrong, but I sometimes think of this as an off-label use of IT, which has been shown to work for other situations, and it just makes sense to try it out in our case too.
    There is no doubt that computers do an excellent job at collecting, storing, analyzing and disseminating Information and therefore are capable of providing great efficiencies for information heavy endeavors. If you think about all the systemic improvements we are expecting from HIT (the I stands for Information), they all hinge on availability and sharing of information.
    Is it so implausible to infer that what happened elsewhere can also happen in health care?

  34. Dear Margalit; I do enjoy your ‘fantasy walks’, however you are in la la land. First of all this doctor who just installed his EMR has no legacy records in his EMR. Whoever installs EMR will take several months to years before this works like this. In addition there will be time lost using a double system of legacy records and an empty data file in the EMR.
    You are correct,, his billing department has quit.
    This doctor must be flush with cash, since he purchased the system out of pocket or took out a loan (which he had a hard time getting, since his credit has gone down the tube trying to make ends meet as reimbursement went down the tube faster than his costs have gone up. He is praying that CMS will be funded for this mandate. There is no definite date when CMS w ill pay the incentive. Or even if it will come in one lump sum. Maybe in your reading you may know the answer to that one. As far as I see this whole incentive business it is to enable physicians to report data to CMS and it is a form of extortion. Word it anyway you want, but that is what it amounts to. If CMS wants this then they should pay up front. I don’t know of any of my vendors that work this way. I thank my lucky stars I am out of this and retired. I will however continue to fight this battle for my colleagues since I am one of the few who has the time and remaining energy to do so.

  35. The “irrelevant” comment was directed to a usual suspect commentor who is just an avowed doctor basher, who is looking strictly for servitude and annhilation(?) of any who resist, sort of a Borg character when you think about it.
    You, Ms G-A, come across as an equally avowed defender that technology will save the system and master efficiency. Yet, I don’t really read you show some caution and hesitance to note the possible consequences.
    I have worn Rose colored glasses, and it gets boring seeing everything in a red tinge. The full spectrum has shades and hues that aren’t all wonderful to see and experience, but, we are talking about life here. Not inhuman efficiency. And aren’t computers made by humans? So, WHEN the defects come to bear, who endures the costs?
    All these movies of futuristic chaos and mayhem, they aren’t from clairvoyance, they are appreciations of past “improvements” that really did not come to bear as advancing us to new and incredible heights.
    So, sorry I do not embrace your positions. You can’t treat what you do not see, hear, touch, and dialogue in person.
    Get dirty in the trenches. You might actually appreciate what we are doing!

  36. Thanks for the response. I agree with most of what you say. The following statement, though, does make me wonder:
    “The savings should come from reduction in test duplication, better care coordination, better prevention, better population management, the much maligned CER, better fraud control, more accurate reimbursement and other system wide improvements.”
    These tasks MAY lead to better health (though the data is preliminary and very sketchy), but there is NO evidence that they will reduce costs overall. Much of what you describe is very labor intensive, and will require a highly trained work force (nurses and MDs) to be done in a way that truly impacts health care. If we’re just going to use HIT to increase our need for an expensive, specialized work force, what are the chances of cutting costs?
    I guess I’m just tired of people making the blanket statement that HIT will cut costs as if it were gospel truth. I think there’s still an enormous amount of confusion as to what we actually want HIT to accomplish in this country (generally, it seems to be some vague wish to “fix” the entire health care system), and that is why implementation has been so slow and problematic.

  37. “The Wagon Queen Family Truckter: you think you hate it now,, just wait ’til you drive it.”
    Just as in “Vacation”, we will hate worse that we can imagine.
    If sucker doc is seeing only 20 patients a day he is closing the doors in a month.
    I say again, I will never play this stupid game. And my patients really like it that way.

  38. Marg stated:”My concern is that, with limited financial means, small private practices are caught in an almost impossible situation here, and I see this as the most unsettling effect of the entire Reform/HITECH business…”
    You also need to be concerned about the fact that this money is buying devices that have not been approved by the FDA and have been reported on the FDA MedWatch site to be defective, injure, kill, and create other risks to the patient. Once it is approved by the FDA and vetted for safety and efficacy as the intermediary between doctor and patient, there may be more willingness to meaningfully embrace it.
    Until then, those of you who have been forced to use HIT and whose patients experienced adverse events or device shut downs, report them to the FDA on line at MedWatch. Anonymous reporting is allowed.

  39. pcp, if you look at any particular private practice, I don’t see anywhere a significant cost savings due to just having an EHR installed. The smaller the practice, the less likely it is to realize any savings due to automation. The classic “benefit” of computerized systems was the ability to reduce payroll. In a small practice, this benefit will not be realized. It is possible that for larger groups and hospitals some benefits of this sort would accrue once the EHR becomes efficient. I do agree with you that we are not seeing this now, but I don’t think we reached the point where EHRs are truly efficient on a localized basis.
    The larger payoff, in my opinion, is going to materialize once EHR systems are interconnected. Again, the small practice will more than likely see no tangible cost reduction, but the health care system as a whole should. The savings should come from reduction in test duplication, better care coordination, better prevention, better population management, the much maligned CER, better fraud control, more accurate reimbursement and other system wide improvements.
    This brings us back to the quintessential question of who should really pay for EHR. Right now, the meager stimulus money notwithstanding, the expectation is that physicians and hospitals should pay for technology. I question the wisdom of this approach since there is no financial incentive attached to it. Perhaps tax payers (Government) wanting to rein in costs of health care should bear a larger burden of this effort. Perhaps insurers, who are certain to benefit as well, should pay for some of the infrastructure.
    My concern is that, with limited financial means, small private practices are caught in an almost impossible situation here, and I see this as the most unsettling effect of the entire Reform/HITECH business.

  40. “We have big problems in health care, mostly associated with cost and access. I don’t believe HIT is the silver bullet for those problems, but I do believe that, in due course, it could modestly contribute to the solution”
    But isn’t it about time we see some solid evidence that HIT will actually reduce costs? We’re seeing lots of reports about hopitals having to hire more nurses to do the data entry, and offices hiring full-time IT specialists (at twice the rate of the transcriptionists they fired-the docs now do their jobs).
    We are seeing lots of cost-shifting, but the idea that HIT will save significant amounts of money for the entire system is looking more and more like a wishful dream.

  41. pcp, Mrs. Kline is not much healthier today and the doc will have to pay for IT.
    EHR will not address reimbursement policy and at this early stage it will not make people healthier.
    As incohate beautifully explains, this is an example of how meaningful use is really not a new concept at all. It does not require changes in how physicians operate today except replacing the paper chart with an electronic one.
    Is it a bit awkward right now? Yes, it is. Is paper completely obsolete and useless? No, it is not. Will things improve as we go along? Yes, they are. Will there be bumps in the road? Plenty.
    Connie, I was wondering when someone will say something about Celebrex for “a touch of arthritis”. Yes, that was my idea of “a touch of humor”, just like the Dermatology resident.
    We have big problems in health care, mostly associated with cost and access. I don’t believe HIT is the silver bullet for those problems, but I do believe that, in due course, it could modestly contribute to the solution, whatever that may be.
    Hello Dr. E, I would suggest you make an effort to keep things in perspective. EHRs will not make doctors irrelevant any more than other technology advances in medicine. When you walk into a hospital today, it looks more like NASA 20 years ago, than anything else.
    Technology is meant to assist. We are not engaged in a war against “the machine”, at least not just yet.

  42. She must have a cadillac insurance plan to cover celebrex to treat a “touch of arthritis”. Didn’t the CDS of this ludicously expensive and time wasting EMR warn the doc of the expense of Celebrex. What did the doc do when the PBM refused to cover it and asked for a list of the other treatments that were tried for arthritis in the past 10 years?

  43. What is this, a TRON Legacy Trailer?
    Sounds great when you hypothesize how smoothly it all plays out. Yeah, but then reality has its ugly way of sticking its head through the smashed door, saying “Here’s Johnny!”
    Reading this column, I see why you are so “passionate” in defending the need for this technology.
    It is your meal ticket, Ma’am. Unbiased and objective, you ain’t!
    Oh, and before Incoherent and Inconsiderate comes flying in for his doctor bombing, yeah, I am not the most unbiased and objective commentor either. I am just trying to help people survive this experience called American culture.
    But, I am sure I&I will have the solution and make all of us MDs irrelevant, eh?

  44. Want to bet that the doc described above pays out more than 25% of his bonus money each year to his IT specialist and to Mary for overtime? In four years, just a lot of big bills and no subsidy, and he hasn’t even begun to pay for his share of the system, updates, increased memory, etc. Sounds great! (And, of course, Mrs. Kline is so much healthier than she was on December 31, 2010).

  45. See my latest REC blog post on some of the operational considerations of Meaningful Use.
    As Dr. Toussaint of ThedaCare observes, “improve it now, perfect it later.”

  46. I like the EMR because it saves on ink pens. This is vital since drug reps can not give out free pens any more. The extra time I must spend clicking and scrolling is all made up for by cut and paste methods of patient care boilerplate that enables me to bill the max for the minimal effort. yippeee!

  47. MD is Hell foretells the end of quacks such as herself: huzzah
    If you “physicians” replying to Margalit are representative of the nation’s ‘trained healers’, I propose we pass out bones & rattles & let people heal themselves.
    Margalit lays out an example – idealized, simplified, get over it – of a medical practice designed to support health professionals’ detection of variances of import in a patient’s health, a still-crude mechanism that supports their sharing of that information with one another and the patient and the patient’s care support family, and your reactions are “the doctor wont be PAID for it!” and “the information isn’t immediately, automatically, comprehensively searchable!” and “I won’t I won’t I WON’T!”
    to blazes with all of your monstrous egos, your disdain for reason, your professional pretentions.

  48. “For some things it is better, for others paper may be more forgiving. Paper certainly is more malleable and in some instances faster for physicians. ”
    Paper! Are you a luddite wannab? Will this not depend on the grade of paper, stiff v soft?

  49. “Everything that involves structured and codified data, such as meds, should improve rapidly as adoption becomes widespread.”
    Why wait? Rid the jabberwock now, bring the usability index above zero.

  50. “I thought this was supposed to be better than paper?”
    Not always. For some things it is better, for others paper may be more forgiving. Paper certainly is more malleable and in some instances faster for physicians.
    In my mind documenting HPI is the most obvious shortcoming of all current EHRs, and probably the most difficult to address.
    Everything that involves structured and codified data, such as meds, should improve rapidly as adoption becomes widespread.

  51. and if you are attending in the hospital and it may have been administered in the hospital 5 admissions ago, then what? click, scroll, search, scroll, click, read the gibberish? I thought this was supposed to be better than paper?

  52. propensity, Show Me is my line… I’m the one from Missouri 🙂
    No there is no search like in Google that goes through the entire EHR and finds a particular word. There are small localized searches, but those will not help here. Implementing a localized search for med lists should be simple, but I haven’t seen one.
    For this case, for this particular patient, I would go to the Med list click on the little arrow (or whatever) on top of the column containing the drug names, which will sort the entire list alphabetically (some EHRs don’t have that), go to the D and see if its there.
    Here’s the good news: by the time you have 19 years of structured data on any patient in any EHR, I guarantee that a search function will be there as well.

  53. Margalit,
    My patient is not doing well and need to try something different. I asked her of she ever was taking digoxin. She was not sure.
    I must then search the EMR to find out if the medication digitalis was ever prescribed in this patient of 19 years loyalty who has been hospitalized 13 times for heart failure, 5 times for chest pain, 4 times for atrial fibrillation, 3 times for GI bleeding and has over 151 visits at the office.
    I want to enter d-i-g-o-x-i-n in the search box, but there is not a search box.
    Well, it is time to scroll though hundreds of screens to see if it was prescribed or considered.,,just perfect for a Monday afternoon with 23 patients on the schedule.
    If anyone of your readers can prove this wrong, ie there is not a search mechanism for anything on EMRs, CPOEs, or EHRs, I stand by ready to watch. Show me.

  54. But Dr. Jones, our fictitious doctor didn’t do anything out of the ordinary. He just went about his day and the little squirrely numbers just fell into place.
    Doctors are, by definition, Meaningful Users. Right now they are meaningful users of paper.
    Billing, unfortunately, has very little to do with quality of care in our current system. EHR will not, and cannot, change that. Perhaps Dr. Berwick will…..

  55. You did a tremendous amount of work for this, Margalit. It made me tired just thinking about the poor doctor, and he/she will be poor as Medicare might pay $47.50 for all of that, and if he/she billed more, the RAC auditors, aka bounty hunters, will investigate and declare excess billing.
    There will not be a link between level of service and meaningful use.
    Thus, you may be a meaningful user of devices that are meaningfully unsafe and you may meaningfully overbill as determined by the well meaning RAC auditors who respectfully and meaningfullyn tell you that you can only meaningfully be paid $32.50.

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